Neck Solutions Blog

Neck pain

From: Med Clin North Am. 2009 Mar;93(2):273-84

Neck pain due to cervical spine and related disorders, although not as common as low back pain, is nonetheless a common and often debilitating problem and an important reason for seeking medical attention. Although patients with neck pain secondary to trauma may be seen initially in an emergency department or in some cases by a specialist, such as an orthopedic surgeon, neck pain more often is spontaneous in onset without correlation with a specific activity or neck trauma. Patients with neck pain frequently see their primary care physician first, which is most appropriate given that many of these patients can be treated effectively without extensive diagnostic testing or referral to a specialist. It is important that the generalist have a good working knowledge of how to evaluate patients with neck pain and the differential diagnosis of disorders of the neck. It is also important to remember that patients presenting with neck and shoulder pain, particularly when it extends into the upper extremities, may have disorders of the brachial plexus rather than a cervical radiculopathy.

Although the approach to history taking for neck pain is similar in many respects to that for low back pain there are enough differences to warrant a separate discussion. Patients with cervical disorders of one type or another may present with lower extremity and bladder or bowel symptoms often with only minimal neck pain. It is important in patients with suspected neck disorders to ask about symptoms referable to lower extremities as well as bladder and bowel functions. This can include questions about the presence of paresthesia in the lower extremities, weakness of the lower extremities, gait disorders, impotence in men, and anorgasmia in women along with bladder disturbances. Sometimes differentiating a peripheral neuropathy, cauda equina syndrome, and cervical myelopathy on the basis of the history is more difficult that one might suspect.

The author continues with some neuromuscular tests helpful in evaluating a patient with neck pain:

• Spurling’s maneuver (test): The head is inclined toward the side of the painful upper extremity and then compressed downward by the examiner. If this induces radiating pain and paresthesia into the symptomatic extremity, it strongly suggests nerve root compression, usually secondary to disk herniation. It should be noted that lateral head movement away from the symptomatic extremity sometimes can accentuate pain and paresthesia in the symptomatic upper extremity secondary to stretching of a compressed nerve root.
• Traction ‘‘distraction’’ test: Lifting ‘‘traction’’ on the head may relieve cervical spinal nerve compression reducing upper extremity pain and paresthesia.
• Valsalva test: As with low back pain/sciatica, the Valsalva maneuver with resultant increased intrathecal pressure can sometimes accentuate neck and upper extremity symptoms when due to an underlying cervical radiculopathy.
• Lhermitte’s test: In patients with myelopathy that affects the posterior columns, neck flexion can produce paresthesia, usually in the back, but sometimes into the extremities. The Lhermitte’s sign is most commonly associated with an inflammatory process such as multiple sclerosis, but it is sometimes noted with spinal cord compression.
• Adson’s and hyperabduction tests: Long used in the evaluation of suspected thoracic outlet syndrome, these tests are nonspecific and unreliable. With the patient sitting erect, the upper extremities at the side (Adson) or symptomatic upper extremity abducted and extended (hyperabduction), the radial pulse is palpated. Each test is positive if the pulse disappears and paresthesia develops in the hand of the symptomatic extremity.

The causes and treatment approach to neck pain are similar to the causes and treatment approach to low back pain. Patients presenting with acute and chronic neck pain generally also complain of neck stiffness and reduced mobility. The pain typically is reduced when the patient is recumbent. As with low back pain, if the pain is not reduced by recumbency, vertebral column infections and metastatic cancer should be considered.

The precise generator of pain usually cannot be identified. The inability to identify a specific etiology is confirmed in part by the lack of precision and specificity of the terms used to describe the syndrome neck strain, musculoskeletal pain syndrome, neck spasms, myofascial pain syndrome, and in the case of chronic and more widespread pain, fibromyalgia. Tendons, ligaments, paracervical muscles, and facet joints all have been implicated as a source of pain, and all may be. However, none can be determined easily in any given patient.

In these patients, diagnostic testing has a low yield, although chronic neck pain patients frequently undergo more than one battery of tests during the course of pain. Although testing has a low yield in a patient with persistent nonradiating neck pain, after several weeks of pain, diagnostic testing may prove necessary to rule out the unexpected, such as congenital malformations of the vertebral column. Although spinal radiographs almost always show spondylotic changes in older patients with nonradiating neck pain, the correlation between symptoms and radiographs is poor. Even if ultimately an MRI of the cervical spine is obtained, results can be misleading because asymptomatic herniated discs are common and may be seen particularly in older patients with unrelated nonradiating neck and low back pain.

In the case of chronic neck pain, as with any chronic pain syndrome, it is crucial to avoid the regular use of reactive pain medications, particularly potentially addictive analgesics. The overuse of analgesics, even nonaddictive analgesics, may lead to analgesic rebound pain.

As with treatment of low back pain, common sense and conservatism are the cornerstones of management. Treatment of acute nonradiating neck pain is largely empiric and may include the following:

• Relative quiescence/pain avoidance, which, if necessary, may include a short period of bed rest. A cervical pillow or towel rolled up and placed under the neck in bed may help. Long-term bed rest is to be avoided.
• Medications including acetaminophen, nonsteroid anti-inflammatory drugs, pain medication when necessary, and possibly muscle relaxants.
• Local application of heat or cold can be tried and then continued if the patient finds either beneficial.
• Bracing (controversial). Short term use of a soft cervical collar or neck brace maybe of value situationally, particularly during the performing of certain necessary activities of daily living such as driving. Long-term, regular use of a collar may actually aggravate the problem by leading to paracervical muscle disuse atrophy.

The author details general findings for radiculopathy, myelopathy and whiplash. The author additionally notes physical therapy in unproven and displays a particular disdain for chiropractors. The author is misleading in attributing a minority philosophical view to a majority of chiropractic practitioners and overstates the risks associated with manipulation of the neck often followed by politically motivated individuals. Otherwise, a very interesting article geared towards general practioners and well worth reviewing.